Case Report Example free essay sample

Centro Escolar University COLLEGE OF OPTOMETRY CLINIC 1 S. Y. 2011 – 2012 Clinicians Name: Year Section: ODP3A Patients Name: CASE # 1 EVALUATION SUBJECTIVE The patient is a 19year-old male Information Technology student of Centro Escolar University. His Gait and Facial Symmetry were good and the head position and speech is normal. He talks clearly and has no unpleasant odor. His reason for visit is to have an eye check up. He complains of constant blurring of vision at far with no associated complains. He is neither a spectacle wearer nor contact lens user service writing indian army He is not taking Multivitamins. OBJECTIVE PRELIMINARY EXAMINATION †¢ VISUAL ACUITY A. Unaided at Distance: 1. OD: 20/25 2. OS: 20/25 3. OU: 20/25 B. Unaided at Near 1. OD: J3 2. OS: J3 3. OU: J2 C. OD is the dominant eye and she uses right hand when writing †¢ OLD RX None †¢ COVER TEST A. Without Rx 1. Exophoria at Distance 2. Exophoria at Near †¢ CORNEAL REFLEX TEST A. We will write a custom essay sample on Case Report Example or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page OD Centric B. OS Centric †¢ DIPLOPIA TEST A. Physiologic Diplopia is present †¢ NPA 1st Trial 2nd Trial 3rd Trial A. OD 13. 33 13. 33 13. 33 B. OS 11. 42 13. 3 11. 42 C. OU 13. 33 13. 33 13. 33 †¢ NPC 1st Trial 2nd Trial 3rd Trial 4. 5/10cm 4. 5/10cm 4. 5/10cm †¢ Pupil size for OU is 5. 0mm with equal and active responses to light (3+) and accommodation (2+) †¢ MOTILITY TEST A. Version – Smooth, Accurate, Full Extensive B. Duction – Smooth, Accurate, Full Extensive C. Saccades – Fast and Accurate II. EXTERNAL EXAMINATION – SLE OU is Normal III. INTERNAL EXAMINATION – Direct Ophthalmoscopy OU findings are Normal (No significant findings) IV. REFRACTION A. Keratometry VMHMMIRESAC OD 44. 000 43. 750 Clear Regular -0. 250Dcyl x 180 OS 44. 250 44. 250 Clear Regular 0 B. Objective 1. Static Retinoscopy ( Net ) OD: -1. 50Dsph = -0. 25Dcyl x 90 OS: -1. 00Dsph = -0. 7 5Dcyl x 180 2. Dynamic Retinoscopy OD: +0. 50Dsph = -0. 25Dcyl x 90 OS: +0. 75Dsph = -0. 75Dcyl x 180 3. Dynamic Retinoscopy OD: +0. 25Dsph = -0. 25Dcyl x 90 OS: +0. 50Dsph = -0. 75Dcyl x 180 C. Subjective 1. VT # 7 Findings OD: -0. 75Dsph20/20 BCVA OS: -0. 75Dsph20/20 BCVA OU20/20 BCVA V. PHOROMETRY DISTANCE |NEAR | |PHORIA | |Lateral |Orthophoria |Orthophoria |Lateral |6Exophoria |4Exophoria | |Vertical |Orthophoria |Vertical |Orthophoria | VERGENCE | |BO |8 |16/10 |BO |6 |16/8 | |BI | | |BI |2 | | |DUCTION | BD |OD |6 |0 |OS |5 |0 |BD |OD |7 |0 |OS |8 |0 | |BU | |5 |0 | |6 |0 |BU | |6 |0 | |7 |1 | | VI. ACCOMMODATIVE TESTS A. AOA 1. OD: 11. 50 2. OS: 10. 25 3. OU: 11. 50 B. PRA -1. 75 C. NRA +2. 75 D. Gradient AC/A Ratio ASSESSMENT Tentative Diagnosis based on the patients complaints: Myopia based on patients complain. Differential Diagnosis based on the series of test conducted: Myopia based on a. Unaided VA at Far and Near b. VT # 7 Findings Simple Myopic Astigmatism based on: a. Static Retinoscopy Final Diagnosis: Myopia PLAN 1. Optical Correction: OU -0. 75Dsph 2. Patient Education and Counseling: a. Inform the patient about the diagnosis and his spectacle grade b. Remind the patient that his prescription eyeglass will not treat his error of refraction but it will just correct it.. therefore he must wear the prescribed glass at all times so to notexperience blurring of vision at far. c. Advise him to eat healthy foods especially vegetables and fruits. d. Recommend him to do follow-up check up at least 6months to 1year to check if themyopia arises or get worsen.